Rethinking Femoral Head Biopsies in Geriatric Hip Fractures: Financial Burden vs Clinical Outcomes.

Introduction: Femoral head specimens are often sent for histopathology after geriatric femoral neck fractures in patients with past history of malignancies. However, the cost-effectiveness of this practice is unclear and the clinical impact and effect on patient management has yet to be ascertained. Methods: This is a retrospective review of all femoral head histopathology specimens registered in our center from 2003 to 2023. Patients <65 years of age were excluded from the study. Patient demographics were analyzed. Clinical notes and radiographic information were retrieved for all cases with positive histopathological findings to delineate any history of (1) atraumatic fractures, (2) prodromal pain and (3) radiological suspicion of pathological fractures. Any changes in subsequent management were also identified and analyzed. Result: From the 1431 cases, the average age was 81.9 ± 7.91 years-old, with 986 females (68.9%). There has been a rising trend of femoral head biopsies over the past 20 years. Only 45 cases had a positive histological diagnosis (3.14%). Among which, 37 of them had radiological features of malignancy (82.2%). Thirty-five cases did not have a history of trauma prior to the fracture (77.8%) and 29 out of 44 cases had documented prodromal pain (64.4%). For the positive cases, just over half (26/45) experienced a change in the subsequent management plan. Majority of cases were managed by palliative intent with adjunctive radiotherapy or bisphosphonate therapy alone. Cost analysis showed the direct cost of pathological examination to be $395.78 USD per case, with an average of $12,585 per positive case. Only 1.8% of femoral neck biopsies were of clinical significance with change in management plans. Conclusion: There is a low positive yield of femoral head biopsies with minimal change in management. Clinical history and radiological features can guide clinicians on the need for femoral head histopathology examinations.